Provider Demographics
NPI:1073899753
Name:LAFAYETTE WOMENS HEALTH
Entity Type:Organization
Organization Name:LAFAYETTE WOMENS HEALTH
Other - Org Name:PREMIER HEALTHCARE FOR WOMEN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:IDESON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:765-428-5888
Mailing Address - Street 1:3774 BAYLEY DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47905-8651
Mailing Address - Country:US
Mailing Address - Phone:765-807-2280
Mailing Address - Fax:765-807-2281
Practice Address - Street 1:3774 BAYLEY DR
Practice Address - Street 2:SUITE B
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47905-8651
Practice Address - Country:US
Practice Address - Phone:765-807-2280
Practice Address - Fax:765-807-2281
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LAFAYETTE WOMENS HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-10-26
Last Update Date:2011-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty